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NeuroRehabilitation 34 (2014) 573–585 DOI:10.3233/NRE-141059 IOS Press

Positive psychology in rehabilitation medicine: A brief report Hilary Bertischa,∗ , Joseph Ratha , Coralynn Longa , Teresa Ashmanb and Tayyab Rashidc a Rusk

Institute of Rehabilitation Medicine, NYU Langone Medical Center, Ambulatory Care Center, New York, NY, USA b Shepherd Center, NW Atlanta, GA, USA c Health & Wellness Centre, University of Toronto Scarborough Student Centre, SL, Toronto, ON, Canada

Abstract. BACKGROUND: The field of positive psychology has grown exponentially within the last decade. To date, however, there have been few empirical initiatives to clarify the constructs within positive psychology as they relate to rehabilitation medicine. Character strengths, and in particular resilience, following neurological trauma are clinically observable within rehabilitation settings, and greater knowledge of the way in which these factors relate to treatment variables may allow for enhanced treatment conceptualization and planning. OBJECTIVE: The goal of this study was to explore the relationships between positive psychology constructs (character strengths, resilience, and positive mood) and rehabilitation-related variables (perceptions of functional ability post-injury and beliefs about treatment) within a baseline data set, a six-month follow-up data set, and longitudinally across time points. METHODS: Pearson correlations and supplementary multiple regression analyses were conducted within and across these time points from a starting sample of thirty-nine individuals with acquired brain injury (ABI) in an outpatient rehabilitation program. RESULTS: Positive psychology constructs were related to rehabilitation-related variables within the baseline data set, within the follow-up data set, and longitudinally between baseline positive psychology variables and follow-up rehabilitation-related data. CONCLUSIONS: These preliminary findings support relationships between character strengths, resilience, and positive mood states with perceptions of functional ability and expectations of treatment, respectively, which are primary factors in treatment success and quality of life outcomes in rehabilitation medicine settings. The results suggest the need for more research in this area, with an ultimate goal of incorporating positive psychology constructs into rehabilitation conceptualization and treatment planning. Keywords: Rehabilitation, brain injury, positive psychology, resilience, function, positive psychotherapy inventory

1. Introduction Over the past decade, interest in character strengths, as defined by traits such as well-being, optimism, engagement, and meaning, as well as positive mood states, has grown considerably under the rubric of “positive psychology.” In January 2000, Martin Seligman,

along with Mihaly Csikszentmihalyi, guest edited a special issue in the American Psychologist on positive psychology, and described the field in their introduction as such:

∗ Address

for correspondence: Hilary Bertisch, PhD, Rusk Institute of Rehabilitation Medicine, NYU Langone Medical Center, Ambulatory Care Center, 240 East 38th Street, 17th floor, New York, NY 10016, USA. Tel.: +1 212 263 2282; Fax: +1 212 263 6807; E-mail: [email protected].

1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved

“A science of positive subjective experience, positive individual traits, and positive institutions promises to improve quality of life and prevent the pathologies that arise when life is barren and meaningless. The exclusive focus on pathology that has dominated so much of our discipline results in a model of the human being lacking the positive

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features that make life worth living. Hope, wisdom, creativity, future mindedness, courage, spirituality, responsibility, and perseverance are ignored or explained as transformations of more authentic negative impulses.” Positive psychology has made tremendous progress in the last decade. Between 2000 and 2010, more than 1,000 articles on topics examining character strengths such as well-being, happiness, and optimism have been published in peer-reviewed journals (Azar, 2011). A classification system of character strengths that apply cross-culturally has been built (Peterson & Seligman, 2004), and initial instruments for measurement have been developed. There is particular enthusiasm regarding the study of interventions that increase character strengths in non-clinical samples, and outcome data supports the use of positive psychology interventions in increasing happiness and reducing depression compared to standard therapeutic approaches and antidepressants in healthy volunteers (Perlman et al., 2010; Seligman, Rashid, & Parks, 2006; Seligman, Steen, Park, & Peterson, 2005). While character strengths have been investigated in normal populations, the field is in its nascency and operational definitions are still in development. White, Driver, and Warren (2008) stated that “a universal definition of resilience does not exist,” although it is known clinically that some individuals are generally more adaptable to traumatic events, including significant medical events, while others appear less so (Dunn, Uswatte, & Elliott, 2009). It has also only been within the past several years that the study of these concepts has been applied to clinical samples, and particularly within rehabilitation medicine, where they may be highlighted following the reductions in quality-of-life often resulting from medical trauma (Majini, 2011). Within the milieu of neurorehabilitation programs, individuals present with sequelae of any number of devastating injuries or illnesses that affect the central nervous system, including traumatic brain injury, stroke, Multiple Sclerosis, brain tumors, and spinal cord injury (SCI). In addition to the significant declines in physical function these conditions can cause, there are also difficulties in cognition and emotional regulation that disrupt daily functioning (Dawson, Schwartz, Winocur, & Stuss, 2007; Silver, McAllister, & Arciniegas, 2009). It is within the framework of multidisciplinary rehabilitation programs that individuals can evidence the character strengths, in particular resilience, necessary

to challenge themselves and rebuild their lives. Because these strengths can now be better identified and nurtured through the developments in the field of positive psychology, rehabilitative potential and overall well-being can be increased (Majini, 2011). As the field of positive psychology continues to expand in a variety of settings, there have been several recent empirical initiatives to study character strengths and resilience within individuals with neurological conditions, and to begin to expand these findings into treatment applications. White, Driver, and Warren (2010) later defined resilience as “an individual’s personal qualities and skills that enable that person to flourish in the face of adversity or a disruptive event (p. 23).” In a sample of inpatients with spinal cord injury, they concluded that resilience was a stable characteristic that did not change from hospital admission to discharge. Resilience inversely correlated with symptoms of depression, and positively with life satisfaction and spirituality. A second study (Quayle & Schanke, 2010) defined resilience as “the ability of adults who are facing a severe and potentially disabling physical injury to maintain relatively stable, healthy levels of psychological and social functioning and to maintain positive emotions and a positive perception of self and the future (p. 13).” The authors reported that in a sample of inpatients with severe multiple trauma or SCI, indicators of resilience were prevalent and contributed to increased satisfaction with social support at hospital admission and discharge, less substance abuse, less fear of dying, and increased feelings of safety (Quale & Schanke, 2010). There is also a growing body of literature that has directly related similar traits such as optimism with improved quality of life in individuals post-ABI (Ramanathan, Wardecker, Slocomb, & Hillary, 2011; Tøien, Bredal, Skogstad, Myhren, & Ekeberg, 2011). Further reports have extended these findings regarding the roles of other strengths such as coping self-efficacy, in addition to optimism and resilience, in patients with diagnoses ranging from traumatic brain injury, Parkinson’s disease, post-polio syndrome, transplants, and severe multiple trauma, within rehabilitation settings (deRoon-Cassini, Mancini, Rusch, & Bonanno, 2010; McCauley et al., 2012; Pierini & Stuifbergen, 2010; Robottom et al., 2012; Tallman, Shaw, Schultz, & Altmaier, 2010). There are even preliminary studies attempting to clarify the neurobiology of characteristics such as resilience within the neuroimaging literature, as an innovative effort to improve pharmacological development for a range of conditions (Russo, Murrough, Han, Charney, & Nestler, 2012).

H. Bertisch et al. / Positive psychology in rehabilitation medicine: A brief report

An ultimate goal of understanding the constructs defined as character strengths and resiliency in the context of rehabilitation is to identify methods of incorporating these characteristics into treatment, with a model of “building positives,” to further improve quality-of-life as an essential part of recovery. Emerging evidence has supported applications of this concept in samples of children with acquired brain injury (ABI), and within the context of “resilience training” for United States military personnel at increased risk for traumatic brain injury (Lester, Harms, Herian, Krasikova, & Beal, 2013; Tonks et al., 2011; Wells et al., 2011). One systematic approach to studying the relevance of character strengths and resilience within rehabilitation settings is to clarify their relationships to factors already known to relate to treatment outcomes, such as use of coping strategies, appraisals or interpretations of stressors, and perceptions of function, health and well-being (Bonanno, Kennedy, GalatzerLevy, Lude, & Elfstr¨om, 2012; Catalano, Chan, Wilson, Chiu, & Muller, 2011; Chan, Lai, & Wong, 2007; Kortte, Stevenson, Hosey, Castillo, & Wegener, 2012). As these relationships are better understood within the frameworks of current standard-of-care models, further initiatives may then be taken to expand them into individualized treatment conceptualization and planning (Tonks et al., 2011). As there has been support for the impact of positive psychology-related constructs on quality of life, the goal of this preliminary study is to augment the existing literature on character strengths, and specifically resilience, in terms of rehabilitation for ABI, by clarifying their relationships to treatment-related factors such as perceptions of functional status and beliefs about treatment. While this study is intended to be exploratory, the overall hypothesis is that (1) overall character strengths, (2) resilience, and (3) positive mood states will correlate with perceptions of functional ability and beliefs about treatment in a heterogeneous ABI sample, both at treatment initiation and at longer-term follow-up.

2. Methods 2.1. Setting Participants were continuously recruited from a large, metropolitan, comprehensive outpatient neurorehabilitation program, specializing in the treatment of adults with heterogeneous ABI diagnoses at various lev-

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Table 1 Demographics of starting sample Characteristic Gender Male Female Race White Black Asian Hispanic Etiology TBI Stroke Other Employment Employed Unemployed Retired SSD/Disability Other/Missing Age at baseline Months between onset and baseline Years of Education

n

%

20 19

51.3 48.7

31 4 3 1

79.5 10.2 7.7 2.6

17 13 9

43.6 33.3 23.1

12 11 8 4 4 Mean 52.62 33.14 16.54

30.7 28.2 20.5 10.3 10.3 SD 18.62 53.3 2.33

els of function. The services provided in this program address both cognitive and emotional difficulties, with treatment goals in these respective domains aimed at improving the individual’s real-world functional ability, independence, and subsequent quality-of-life. Because of the diagnostic heterogeneity found in our program, patients are conceptualized by level of functional impairment at intake, rather than by type or severity of injury per se. In this classification system, patients are assigned to treatments based upon a levels-ofresidual-competence model, with sets of behaviorally observable criteria delineated for each level (Bertisch, Rath, Langenbahn, Sherr, & Diller, 2011; Langenbahn, Sherr, Simon, & Hanig, 1999; Sherr & Langenbahn, 1992). 2.2. Participants Participants were 39 individuals between 23–85 years of age. While the gender ratios in the present study were slightly more equivalent as compared to available data from similar rehabilitation programs treating individuals with heterogeneous ABI diagnoses, other demographic characteristics were generally comparable (see Table 1; Bancroft Brain Injury Rehabilitation, 2012; May Institute for Neurorehabilitation, 2013; Memorial Hermann Rehabilitation & Research, 2013). For inclusion in his study, all participants had to (1) have a diagnosis of any ABI, (2) have had fewer than five

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treatment sessions, and (3) have ability to comprehend the measures included (including adequate command of the English language), as per performance on neuropsychological testing at intake. Participants were excluded if (1) they were not treated on the clinical service, (2) if their initial treatment plan was short-term (less than four months), thereby making them unlikely to reach followup phase, (3) they were unable to read or complete the assessments, or (4) if they were not interested in participating in clinical research. Recruitment lasted from December, 2010 until September, 2011. During this period, a total of 110 participants were targeted for participation. Within this sample, 35.5% (n = 39) agreed to participate, 38% (n = 42) failed to meet the above inclusion/exclusion criteria, and 26% (n = 29) did not return after initial evaluation for clinical service. Twenty-five participants completed follow-up assessments, while nine (23%) left treatment prior to the four-monthrequirement for treatment-related reasons, and only five (13%) participants refused to complete follow-up evaluations. This attrition rate was as expected for an outpatient psychological service (Bados, Balaguer, & Salda˜na, 2007; Edlund et al., 2002; Sharf 2008). The mean follow-up period was 26.96 (SD = 4.02) weeks from baseline. 2.3. Procedures During recruitment, all patients who met the inclusion criteria were queried about their interest in participation, and consented within their first four sessions of treatment. After consent, participants were given assessment packets to take home, so that they could be completed at their own pace and at their convenience. Assistance with reading or writing was provided by study personnel for participants with disabilities that interfered with their ability to complete the forms (two patients requested assistance during baseline; only one of these patients requested assistance during follow-up). Approximately six months after baseline assessment was completed, participants were contacted to complete the second time-point evaluation. The same procedures from baseline were repeated. This study has IRB approval by New York University School of Medicine. 2.4. Assessment For each participant, a general demographic form including age, gender, diagnosis, length of time since injury, present medical status, level of education, and

types of rehabilitation services enrolled in was collected. 2.4.1. Positive psychology constructs 1) The Positive Psychotherapy Inventory (PPTI; Rashid, 2008; Appendix A). The PPTI is a general measure of character strength that is deeply rooted in Seligman’s theories of positive psychology (2000). The self-report measure consists of 21 Likert-type items from which a “Pleasant Life” score, an “Engaged Life” score, a “Meaningful Life” score, and an “Overall Happiness” index are derived. Individual items measure character strengths such as gratitude, connection with others, purpose, well-being, and positive mood as observed by others. The PPTI has demonstrated good internal consistency, test-retest reliability, factor analysis, and convergent validity for use cross-culturally in healthy and clinical (i.e., outpatient mental health) populations (Guney, 2011; Rashid, 2008). Within the present sample of individuals with ABI, reliability analyses showed that all four PPTI indices had high internal consistency during baseline data collection: Pleaseant Life (␣ = 0.84), Engaged Life (␣ = 0.69), Meaningful Life (␣ = 0.76), and Overall Happiness (␣ =0.88). Further, all subscales were moderately and significantly correlated (r = 0.540 to 0.588), thereby suggesting adequate construct validity. To reduce the number of variables included in the present analyses, only the PPTI total “Overall Happiness” index was used as the primary index of character strength. 2) Connor-Davidson Resilience Scale (CD-RISC; Connor & Davidson, 2003). This measure defines resilience in terms of stress coping ability, and has been normed in both healthy samples and primary care outpatients. It consists of five factors with 25 items rated on a 0–4 scale, with higher scores reflecting greater resilience. The CD-RISC has good psychometric properties and has been a primary measure utilized in studies of resilience in rehabilitation medicine (Shin, Goo, Yu, Kim, & Yoon, 2012; White et al., 2010). The total CDRISC score was used in this study as a measure of resilience. 3) Profile of Mood States (POMS; Lorr, McNair, & Droppleman, 2003). The POMS is a self-report measure used to identify six fluctuating mood states. It has 65 items and takes approximately 10 minutes to complete. The POMS has been normed

H. Bertisch et al. / Positive psychology in rehabilitation medicine: A brief report

in both healthy and medical outpatient samples and has been used in research, particularly in samples with neurological disorders and spinal cord injury (Arruda, Stern, & Sommerville, 1999; Affiliations; Davidson, 2002; Driver & Ede, 2009; Wijesuriya, Craig, Tran, & Middleton, 2011). As this study is designed to evaluate the effects of positive characteristics, only the POMS Vigor-Activity scale, which measures positive mood, was selected for the present analyses. 2.4.2. Rehabilitation-related variables 1) Head Injury Family Interview (HiFi; Kay, Cavallo, Ezrachi, & Vavagiakis, 1995). The HiFi is a structured interview designed for systematic data collection from patients and/or family members regarding symptomotology post-ABI. Within the HiFi, the Problem Checklist (PCL) is a 43-item rating scale, in which specific symptoms in the emotional, cognitive, and physical domains are rated on a seven-point scale, ranging from 1 to 7, in which “1” indicates that the symptom is “no problem” in terms of impact on daily functioning, “4” represents a “moderate problem,” and 7 represents a “severe problem” in terms of daily function. In contrast to other commonly-used functional measures that are either intended for use with individuals with extreme impairment (e.g., emergence from coma) or target fewer areas of deficit (e.g., Disability Rating Scale, Hall, Cope, & Rappaport, 1985; Glasgow Coma Scale, Hall et al., 1985; Mayo–Portland Inventory (4th Edition), Malec & Thompson, 1994; Moss Attention Rating Scale, Hart, Whyte, Ellis, & Chervoneva, 2009; Post-Acute Level of Consciousness Scale, Eilander et al., 2009), the HiFi PCL has a relatively broad range of functional domains and severity of impairment, considerations that were crucial to its selection as the functional outcome measure for this study. The HiFi PCL has demonstrated good clinical utility, excellent reliability, and demonstrates validity against comparable measures, such as the Patient Competency Rating (Fourtassi et al., 2011; Kashluba, Paniak, & Casey, 2008; Kay et al., 1995; Nabors, Seacat, & Roenthal, 2002; Seel, Kreutzer, & Sanders, 1997). The HiFi PCL has been used in prior ABI research (Bertisch et al., 2013; Paniak et al., 2002; Rath et al., 2004; Struchen, Pappadis, Sander, Burrows, & Myszka, 2011). For the purposes of this study, an abbreviated version of the HiFi PCL was completed by

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each participant as part of the assessment packets, and used as an index of perception of function post-ABI. 2) Expectations of/Satisfaction with Treatment Scale: These Likert-type measures of expectations of and satisfaction with treatment, respectively, are typical of ratings used in psychotherapy outcome studies, and were adapted for our treatment program (Heppner, Cooper, Mulholland, & Wei, 2001). They each consist of 12 items that reflect expectations of, and satisfaction with, various components of a rehabilitation program, with direct application to cognitive rehabilitation for individuals with ABI. Items include “I expect to be/I am satisfied with therapy,” and “My needs will be/are being met by the program,” and are rated on a 1 to 6 point Likert scale. The measure reflecting expectations of treatment was administered at baseline, and the corresponding satisfaction scale was administered at six-month follow-up. 2.5. Data analysis Correlations between the positive psychology variables (PPTI, CD-RISC, and POMS) were implemented as an initial analysis, in an effort to maximize efficiency in variable selection while reducing the possibility of Type I error, due to common variance between these indices. Histograms for the rehabilitation-related variables: (1) HiFi PCL pre-test, (2) Expectations of Treatment (3) HiFi PCL post-test, and (4) Satisfaction with Treatment were also reviewed, in order to assure appropriate variability in these measures for analysis. Accounting for the small, albeit adequately powered sample size (Cohen, 1992) and exploratory nature of the present study, Pearson correlations were conducted as the primary analysis to examine the relationships between the positive psychology variables (character strengths, resilience, and positive mood), and the rehabilitation-related variables (perceptions of function and expectations of/satisfaction with treatment). The correlations of greatest interest were: (1) PPTI, CD-RISC, and POMS in relation to the HiFi PCL and Expectations of Treatment scales within the baseline data, (2) PPTI, CD-RISC, and POMS in relation to the HiFi PCL and Satisfaction with Treatment scales within the follow-up data, and (3) PPTI, CD-RISC, and POMS baseline data in relation to the HiFi PCL and Satisfaction with Treatment scales at follow-up, in an effort to better

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H. Bertisch et al. / Positive psychology in rehabilitation medicine: A brief report Table 2 Correlations between outcome measures Baseline measures

Baseline

HiFi

EOTS

Follow-up

HiFi

SWTS

Pearson r Sig. n Pearson r Sig. n Pearson r Sig. n Pearson r Sig. n

Follow-up measures

PPTI

CD-RISC

POMS V/A

PPTI

CD-RISC

POMS V/A

−0.66** 0.000 35 −0.15 0.391 36 −0.50* 0.013 24 −0.04 0.853 23

−0.54** 0.001 35 −0.41* 0.014 36 −0.26 0.226 24 −0.14 0.517 23

−0.34 0.057 33 −0.53** 0.002 33 −0.13 0.579 22 −0.41 0.066 21

– – – – – – −0.49* 0.018 23 0.08 0.722 22

– – – – – – −0.53** 0.008 24 −0.09 0.683 23

– – – – – – −0.49* 0.020 22 −0.13 0.595 20

**Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed). PPTI = Positive Psychotherapy Inventory, CD-RIS = Connor-Davidson Resilience Scale, POMS V/A = Profile of Mood States – Vigor/Activity Scale, HiFi = Head Injury Family Interview, EOTS = Expectation of Treatment Scale; SWTS = Satisfaction with Treatment Scale.

understand the implications of initial indicators of positive psychology on longer-term rehabilitation-related factors. 3. Results 3.1. Examination of multicollinearity and distributions of criterion ratings As the constructs of character strengths, positive mood, and resilience are conceptually related, these variables subsequently evidenced moderate to strong empirical correlations within the baseline (r = 0.60 to r = 0.71) and follow-up data sets (r = 0.68 to r = 0.85). In order to reduce the effects of the inter-correlations within the positive psychology constructs on those correlations between these and the rehabilitation related variables, only one essential score from each positive psychology measure was selected for the correlations within this study. Descriptive statistics and histograms for each of the rehabilitation-related variables, (1) HiFi PCL baseline, (2) HiFi PCL follow-up, (3) Expectations of Treatment and (4) Satisfaction with Treatment, evidenced sufficient variability for inclusion as criterion variables (HiFi PCL pre-test M = 100, SD = 36; HiFi PCL post-test M = 93, SD = 30; Expectations of Treatment M = 21, SD = 7; Satisfaction with Treatment M = 18, SD = 7). 3.2. Results of proposed correlations Results of correlational analyses are shown in Table 2. At baseline, there were moderate to strong asso-

ciations between character strengths and perceptions of function (r = −0.66, p < 0.001), and between resilience and perceptions of function (r = −0.54, p < 0.001). Within the follow-up data set, there were moderate correlations between all three positive psychology indices: character strengths (r = −0.49, p < 0.05), resilience (r = −0.53, p < 0.01), and positive mood (r = −0.49, p < 0.05) with perceptions of function. Character strengths at baseline were also moderately correlated with perceptions of function at follow-up (r = −0.50, p < 0.05). As the HiFi PCL is rated on a negative scale, all correlations against this measure were in the expected directions. At baseline, both resilience (r = −0.41, p < 0.05) and positive mood (r = −0.53, p < 0.01) were moderately correlated with expectations of treatment, with low scores indicating higher expectations of/satisfaction with treatments on this measure. There were no significant correlations between the positive psychology constructs and satisfaction with treatment within any of the analyses. 3.3. Supplementary analyses Due to the small N within this pilot sample, options for appropriate analyses were limited (Cohen, 1992). A series of multiple regression analyses (MRA) was therefore conducted on a supplementary basis to determine the potential predictive value of the inclusive positive psychology constructs on the rehabilitationrelated variables, and to support the a priori correlations described above. Stepwise MRA was selected as it was hypothesized that there would be overall effects of the three predictor variables (PPTI, CD-RISC, and POMS)

H. Bertisch et al. / Positive psychology in rehabilitation medicine: A brief report

on the rehabilitation-related variables (HiFi PCL and Expectations of/Satisfaction with Treatment), but there was no expected effect of their order of entry into the equation. Three sets of MRA were conducted: 1) within the baseline data only, 2) within the followup data only, and finally, 3) with baseline predictors and follow-up criterion data, in an effort to predict longer term-treatment implications from baseline positivity and resilience ratings. For each analysis, length of time since onset was entered into the first step of the equation, and the other predictor variables were entered into the second step of the equation. As a complement to the proposed correlations, these MRA indicated that the PPTI total scores significantly predicted HiFi PCL total scores within the baseline data set (F [2, 30] = 10.60, p < 0.001), within the followup data set (F [2, 19] = 6.54, p < 0.01) and within the longer-term predictions between baseline positivity variables and HiFi PCL follow-up scores (F [2, 20] = 4.85, p < 0.05). Across these analyses, PPTI accounted for 65.6%, 43.5%, and 59.2% of the variance in HiFi PCL total scores, respectively. Length of time since onset, the POMS Vigor-Activity scale, and the CD-RISC had no significant effects on the criterion variables in any of the analyses, and no variables significantly predicted expectations of treatment at baseline, or satisfaction with treatment at follow-up. Limitations in the MRA results may again be due to the small sample that precluded implementation of these analyses as primary in this pilot study.

4. Discussion The results of this preliminary study provide initial evidence to support relationships between character strengths and perceptions of functional ability post-brain injury within the baseline and six-month follow-up data sets, and longitudinally from treatment initiation to six-month follow-up. Resilience and character strengths were related to perceptions of functional ability within the baseline data and follow-up data sets, and positive mood correlated with perceptions of functional ability at follow-up. In addition, both resilience and positive mood were related to positive expectations of treatment within the baseline data set. Collectively, these findings suggest that character strengths, resilience, and positive mood may contribute to both short and longer-term perceptions of functional ability and expectations of treatment, which have been shown to contribute to quality-of-life in studies of patients with

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neurological conditions (Cicerone & Azulay, 2007; Hampton, 2000; Robinson-Smith, Johnston, & Allen, 2000; Tsaousides et al., 2009). While relationships between depression, perceptions of functional ability, and quality-of-life are well-documented in the rehabilitation literature (Breir et al., 1998; Hibbard et al., 2004; Hudak, Hynan, Harper, & Diaz-Arrastia, 2012; Mitchell, Benito-Le´on, Gonz´alez, & Rivera-Navarro, 2005; Pagulayan, Hoffman, Temkin, Machamer, & Dikmen, 2008), there are few studies that have examined the role of positive functioning independent of negative symptoms. The most robust correlate and predictor of perception of function across time points was the PPTI, the primary measure of character strength in this study. Similarly, the CD-RISC, the main indicator of resilience, correlated with perception of function at both baseline and follow-up. These results indicate that positive character traits, and specifically resilience, significantly impact the way in which individuals may positively evaluate their strengths and functionality following a traumatic injury or illness. Furthermore, resilience correlated with expectations of treatment at baseline, suggesting that individuals with stronger internal resources may view treatment as a means of enhancing their existing resources, even prior to treatment commencement. As the available research suggests a relationship between character strengths, resilience, coping selfefficacy, and quality of life in rehabilitation medicine samples, our findings indicate that enhancement of these kinds of positive traits, for instance through training on improved coping strategies, within rehabilitation medicine would likely contribute to decreased experience of symptoms, improved perceptions of function, and ultimately better treatment outcomes (deRoonCassini, Mancini, Rusch & Bonanno, 2010; McCauley et al., 2012; Pierini & Stuifbergen, 2010; Robottom et al., 2012; Tallman, Shaw, Schultz, & Altmaier, 2010). In addition to the potential role of stable character strengths in influencing perceptions of both function and treatment, our findings also suggest a relationship between positive mood and these rehabilitation-related variables. The POMS, which was the primary indicator of positive mood in this study, correlated significantly with expectations of treatment at baseline and perceptions of function at follow-up. It also demonstrated moderate correlations and non-significant trends with perceptions of function at baseline and satisfaction with therapy longitudinally, which may have reached significance in a larger sample. These findings suggest that in addition to enhancement of inherent character

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strengths, improvement of state-dependent mood is an important objective towards augmenting perceptions of function and beliefs about treatment. In particular, as positive mood correlates with treatment expectations, which is an important factor underlying success of psychological treatments (Tsai, Ogrodniczuk, Sochting, & Mirmiran, 2012; Vogel, Wester, Wei, & Boysen, 2005), enhancement of mood early in treatment may have longer-term implications for both response to intervention and quality-of-life outcomes. As the applications of positive psychology continue to emerge within rehabilitation medicine, our findings indicate that in addition to addressing depression, supporting positive moods and character strengths may be directly relevant to treatment success (Dunn & Dougherty, 2005; Evans, 2012; Majani, 2011; Tonks et al., 2011; Wells et al., 2011). One important consideration unique to rehabilitation medicine in the study of character strengths and perceptions of functional ability post-injury is anosognosia, or organically-based unawareness of deficits, secondary to brain injury. Patients experiencing anosognosia report less depression, and perhaps would subsequently report greater strengths, optimism, and well-being, that is clinically associated with decreased awareness of their injuries and subsequent functional limitations (Lucas & Fleming, 2005; Malec, Testa, Rush, Brown, & Moessner, 2007; Prigatano, 2009). While evaluation of the effects of anosognosia was beyond the scope of the present study, it is necessary to consider the balance between awareness, self-report of positive traits, functional ability, and reactions to treatment, particularly when integrating these constructs into rehabilitation conceptualization and planning. Other methodological limitations of the present study include a small, albeit adequately-powered sample to detect a large effect size (Cohen, 1992), heterogeneity of diagnoses, limited theoretical orientations within the field of positive psychology beyond Seligman’s model on which to base methodology, limitations in available operational definitions and subsequent measures of character strengths and positive mood states that are appropriate for a rehabilitation population, and inter-correlations between the positive psychology indices. While these factors were controlled to the extent possible in the present study design through careful selection of indices to include the analyses, they may have obscured more subtle relationships between the variables of interest. This study is among the first of its kind to investigate the relationships between character strengths, resilience, and positive mood states and rehabilitation-

related variables in an outpatient ABI sample within and across time points in treatment. As the applications of positive psychology to rehabilitation medicine continue to grow, there is an essential need for development of clearer operational definitions and appropriate instruments to measure these constructs as they apply to individuals with ABI. In addition, interventions already exist to increase factors such as resilience and happiness in healthy volunteers and in child and military samples (Perlman et al., 2010; Seligman, Rashid, & Parks, 2006; Seligman et al. 2005; Tonks et al., 2011; Wells et al., 2011), and there is a growing consensus that in order to be maximally effective, neuropsychological rehabilitation must address both objective cognitive deficits and subjective attitudinal, motivational, and emotional factors (e.g., self-efficacy, confidence, self-esteem) in tandem. As such, building empirically validated positive psychology treatment models is crucial to maximizing rehabilitative potential and research within adult civilian populations as well (e.g., Ben–Yishay & Diller, 2011; Cicerone et al., 2005, 2011; Cicerone & Azulay, 2007; Gordon, Cantor, Ashman, & Brown, 2006; Mateer, Sira, & O’Connell, 2005; Montgomery, 1995; Prigatano, 2003; Schutz & Trainor, 2007; Wilson, 2005). Once further progress has been made in terms of these definitions, measurements, and systematic treatment methodologies, these constructs can be better evaluated, and new methods to incorporate the principles of positive psychology interventions into rehabilitation treatment planning can take place.

Declaration of interest The authors of this study have no financial or personal interests to declare at this time.

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Appendix A POSITIVE PSYCHOTHERAPY INVENTORY (PPTI) Rashid, T. (2008). The positive psychotherapy inventory. In Magyar-Moe J, Therapist’s Guide to Positive Psychological Interventions (pp. 86-90). Oxford, UK: Academic Press in Elsevier. Please read each group of statements carefully. Then, pick the one statement in each group that best describes you. Be sure to read all of the statements in each group before making your choice. Some questions are regarding strengths. Strength refers to a stable trait which manifests through thoughts, feelings and actions, is morally valued and is beneficial to self and others. Examples of strengths include but not limited to optimism, zest, spirituality, fairness, modesty, social intelligence, perseverance, curiosity, creativity, teamwork... etc. In responding to statements regarding strengths, it is important that you distinguish between strengths, abilities and talents. Abilities and talents are attributes such as intelligence, perfect pitch, or athletic prowess.

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Strengths fall in moral domain whereas abilities and talents do not. Talents and abilities seem to have more tangible consequences (acclaim, wealth) than strengths. Someone who “does nothing” with a talent like high IQ or musical skill courts eventual disdain. We may experience dismay when extremely talented individuals like Judy Garland, Michael Jackson, Elvis Presley, are overwhelmed by drugs and other problems. In contrast, we never hear the criticism that a person did nothing with her wisdom or kindness. Put simply, talents and abilities can be squandered, but strengths cannot. Nevertheless, strengths, abilities and talents are closely linked. Think of famous basketball player Michael Jordan. He is revered for his athletic ability but also for his refusal to lose. 1. Joy 0. 1. 2. 3.

I rarely feel joyful. I occasionally feel joyful I feel more joyful than joyless I usually feel joyful.

2. Knowing strengths 0. 1. 2. 3.

I do not know my strengths. I have some idea about my strengths. I know my strengths. I am very well aware of my strengths.

3. Impact on society 0. 1. 2. 3.

What I do usually does not matter to society. What I do occasionally matters to society. What I do often matters to society. What I do usually matters to society.

4. Positive mood observed by others 0. 1. 2. 3.

Others say I usually do not look happy. Others say I occasionally look happy. Others say I usually look happy. Others say I look happy most of the time.

5. Pursuing Activities 0. I usually do not pursue activities which use my strengths. 1. I occasionally pursue activities which use my strengths. 2. I often pursue activities which use my strengths. 3. I usually pursue activities which use my strengths.

6. Sense of connection 0. I do not feel connected to people with whom I regularly interact. 1. I occasionally feel connected to people with whom I regularly interact. 2. I often feel connected to people with whom I regularly interact. 3. I usually feel connected to people with whom I regularly interact. 7. Gratitude 0. I usually do not take time to think about the good things in my life. 1. I occasionally notice good things in my life and feel thankful. 2. I often notice good things in my life and feel thankful. 3. I feel grateful for many good things in my life almost every day. 8. Solving problem using strengths 0. 1. 2. 3.

I rarely use my strengths to solve problems. I occasionally use my strengths to solve problems. I usually use my strengths to solve problems. I often use my strengths to solve problems.

9. Sense of meaning 0. 1. 2. 3.

I rarely feel like my life has a purpose. I occasionally feel like my life has a purpose. I often feel like my life has a purpose. I usually feel like my life has a purpose.

10. Relaxation 0. 1. 2. 3.

I rarely feel relaxed. I occasionally feel relaxed. I often feel relaxed. I usually feel relaxed.

11. Concentration during strength activities 0. My concentration is poor during activities which use my strengths. 1. My concentration is sometimes good and sometimes poor during activities which use my strengths. 2. My concentration is usually good during activities which use my strengths. 3. My concentration is excellent during activities which use my strengths.

H. Bertisch et al. / Positive psychology in rehabilitation medicine: A brief report

12. Religious or spiritual activities 0. I usually do not engage in religious or spiritual activities. 1. I occasionally spend some time in religious or spiritual activities. 2. I often spend some time in religious or spiritual activities. 3. I usually spend some time every day in religious or spiritual activities.

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17. Managing strength activities 0. It is usually hard for me to manage activities which use my strengths. 1. I can occasionally manage activities which use my strengths. 2. I often can manage well activities which use my strengths. 3. Managing activities which use my strengths comes almost natural to me.

13. Savouring 0. I usually rush through things and don’t slow down to enjoy them. 1. I occasionally savour at things that bring me pleasure. 2. I savour at least one thing that brings me pleasure every day. 3. I usually let myself get immersed in pleasant experiences so that I can savour them fully. 14. Time during strength activities 0. Time passes slowly when I am engaged in activities that use my strengths. 1. Time passes ordinarily when I am engaged in activities that use my strengths. 2. Time passes quickly when I am engaged in activities that use my strengths. 3. I lose the sense of time when I am engaged in activities that use my strengths. 15. Closeness with loved ones 0. 1. 2. 3.

I usually do not feel close to my loved ones. I occasionally feel close to my loved ones. I often feel close to my loved ones. I usually feel close to my loved ones.

16. Laughing/smiling 0. 1. 2. 3.

I usually do not laugh much. I occasionally laugh heartily. I often laugh heartily I usually laugh heartily several times each day

18. Contributing to something larger 0. I rarely do things that contribute to a larger cause. 1. I occasionally do things that contribute to a larger cause. 2. I often do things that contribute to a larger cause. 3. I usually do things that contribute to a larger cause. 19. Zest 0. 1. 2. 3.

I usually have little or no energy. I occasionally feel energized I often feel energized I usually feel energized.

20. Accomplishment in strength activities 0. I do not feel a sense of accomplishment when I spend time in activities which use my strengths. 1. I occasionally feel a sense of accomplishment when I spend time in activities which use my strengths. 2. I often feel a sense of accomplishment when I spend time in activities which use my strengths. 3. I usually feel a sense of accomplishment when I spend time in activities which use my strengths. 21. Using strengths to help others 0. I rarely use my strengths to help others. 1. I occasionally use my strengths to help others, mostly when they ask. 2. I often use my strengths to help others. 3. I regularly use my strengths to help others.

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